Dental Trauma in the ED: Fractures and Luxations

1. Dental Trauma in the ED: Fractures and Luxations Resident Grand Rounds Elizabeth Haney 10 May 2007

2. Outline • Review of anatomy, and pertinent basics • Injury Overview • Management • New products coming and how to use them Thanks to Dr. Greenfield, Dr. Kalaydjian and Dr. Lobay

3. Goal • For you to leave today feeling more confident with your management and disposition of dental injuries.

4. Emerg Issues in Dental Injuries • Pain Management • Oral Meds • Nerve Blocks • Covering the Exposed Root • Keep tooth alive • Transient Storage Media • Stabilization until definitive management (ie: referral to our Dental colleagues) • Periodontal Paste

5. Numbers in the CHR • Interrogation of CHR initial complaints • April 1 2006 – March 31 2007 • FMC, RGH, PLC • 1868 Dental/Oral related visits as primary complaint • 2006 Health Records Info • 196 discharge codes for Dental specific Dx

6. Anatomy of a Tooth

7. Which tooth is it? • Numbering System Differences • 32 adult teeth • 4 incisors (most commonly injured) • 2 canines • 4 premolars • 6 molars

8. Tooth Surface Terminology • Lingual surface faces tongue • Buccal surface faces cheek • Mesial surface faces midline • Distal surface faces ramus of mandible

9. Fractures • Ellis classification used in Emerg • General description used/preferred by Dentists • ie: instead of Ellis III, saying # exposing the pulp

10. Enamel Fractures • Non – painful • Chalky white appearance • Reassurance • Consider filing sharp edges • Non-urgent Dentistry referral

11. Dentin Fractures • May have sensitivity (temp, air, percussion) • Yellow dentin visible • Management: • Block the tooth • Dry tooth • Cover the tooth (CaOH) • Dental f/u within 24h

12. Pulp Fractures • Yellow dentin and pink blush or frank blood • Usually Painful • Block the tooth • Dry the tooth • Cover the tooth (Calcium Hydroxide) • Dental Consult if unable to manage pain • Most require eventual root canal

13. Fractures Summary • All require Dentistry follow-up • Enamel #’s: non-urgent (1-2 weeks) • Dentin #’s: within 24 hours • Pulp #’s: Immediate if possible, next day at latest

14. Subluxation, Luxation, Avulsion • Subluxation – Loose Tooth • Luxation – Displaced Tooth • Intrusive: displaced into socket (apically) • Extrusive: displaced out of socket • Lateral: displaced any other way • Avulsion – Completely Out • Pain Control!

15. Subluxation • Increased mobility due to torn PDL fibers • Tender to touch • Not displaced • If minimally mobile • Soft diet • Non-urgent dental f/u • If grossly unstable • Stabilize: Dentist Consult, or stabilize in ED and Dentist in AM

16. Intrusive Luxation • Apical displacement into alveolar bone • Crushes PDL +/- neurovascular supply rupture • Immobile • R/O avulsion if completely intruded • Consult Dentistry – semi-urgent basis

17. Extrusive Luxation • Tooth appears long • Mobile • Gently reposition into socket • Stabilize • Consult Dentistry

18. Lateral Luxation • Tooth displaced, apex moved close to bone • Usually immobile • Reposition • Stabilize • Consult Dentistry

19. Avulsion • Completely out of socket • Torn PDL w/ fragments on root and in socket • Locate tooth! • Place the avulsed tooth in cold, isotonic solution • Consult Dentistry • 1% chance of successful reimplantation lost q1min out of socket (dry)

20. General Avulsion Guidelines • Handle tooth by the crown (Minimize PDL damage)  • Transport in appropriate media (next slide) • Gently rinse (wiping can remove PDL) • Flush socket with saline • In ED, replant tooth, stabilize

21. Tooth Storage Media • Order of Preference: • Hank’s (ph) balanced salt solution (HBSS) • Cold milk • Saliva • Saline • Water • NEVER Dry Ozan et al. J Endod May 2007

22. Find the Tooth!

23. Dentistry Splinting Estimates

24. Stabilization and Capping Products • Periodontal Paste & Calcium Hydroxide • Do we have them in the ED? • NO. Not yet • I’m working on getting us samples and will keep you posted via e-mail

25. New Products and How to Use Them • Coe-Pak • Surgical dressing & Periodontal pack • Supplied in 2 tubes: base & catalyst • Mix together into paste • Roll into appropriate width & length • Press against mucosa and teeth, flanking the injured tooth • Do not cover occlusal surface

26. Ca Hydroxide • Rigid self-setting material used for pulp capping & as a protective base/liner under dental filling materials • Supplied in 2 tubes: base & catalyst • Dispense equal volumes onto paper • Stir using applicator until uniform color (~10sec) • Apply to dried area • Remove excess • Set time: 2-3 min on paper, less in mouth

27. It’s 2am….Do I Call the Dentist? • Dental Emergencies: • Avulsion • Fracture to Pulp, if unable to control pain • Any luxation • Dental Hemorrhage • Abscess needing drainage which is beyond our scope • Jaw # - OMF surgeon • If they’re coming in  Order a Panorex Thanks Dr. Kalaydjian

28. CHR Dentist’s On-Call Policy • Full coverage • Each dentist 1 call q 2-3 weeks • Call back within 5-10 minutes, able to be at hospital within 30 minutes • No formal compensation (only if pt pays) • Great policy on helping ED pts! • Be Kind 

29. CHR Resources • CHR Dental Clinic: Only medically compromised patients as regulars • CHR funded Community Dental Clinics: Patients pay 20% of actual fee • Call 228-3384 = “22-teeth” • Sites: City Hall Dental Clinic, Northeast Dental Clinic (Sunridge Mall), Airdrie • www.calgaryhealthregion.ca/hecomm/oral/reducedfeedental.htm

30. Take Home Points • Know the terminology, or where to find it • Proper communication = Happier consultants • Manage the pain • We temporarily manage these injuries • Definitive management left to the pros • Know your tools and resources

31. Future Initiatives • Stocking of Stabilization and Capping products • Dental Trauma Patient Instructions • Dedicated space in the Emerg for a dentistry locked box of supplies

32. References • Marx. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 6th ed. 2006. ch. 69 Oral Medicine • Andersson et al. Guidelines for the management of traumaticdental injuries. I. Fractures and luxations of permanent teeth. Dental Traumatology 2007; 23: 66-71 • Becker et al. Drug Therapy in Dental Practice: Nonopioid and Opioid Analgesics. Anesth Prog 2005; 52:140-149 • Dale RA. Dentoalveolar trauma. Emerg Med Clin North Am 2000;18: 521-38 • Po AL, Zhang WY: Analgesic efficacy of ibuprofen alone and in combination with codeine or caffeine in post-surgical pain: A meta-analysis.  Eur J Clin Pharmacol  1998; 53:303 • Benko et al., Management of Dental Emergencies. EM Reports. Vol 27, N. 3. January 2006 • Lynch MT, Syverud SA, Schwab RA, et al: Comparison of intraoral and percutaneous approaches for infraorbital nerve block.  Acad Emerg Med  1994; 1:514 • Harkacz O, Carnes D, Walker W. Determination of periodontal ligament cell viability in the oral rehydration fluid Gatorade and milks of varying fat content. J Endod 1997;23:687–90 • Ozan et al. Effect of Propolis on Survival of Periodontal Ligament Cells: New Storage Media for Avulsed Teeth. J Endod 2007;33:570-573 • EMRap November 2006 Dental Trauma • www.calgaryhealthregion.ca/hecomm/oral/reducedfeedental.htm

33. Extra Slides

34. Useful Nerve Block Review • Supraperiosteal - Individual Teeth • Infraorbital – Maxillary Teeth and Upper Lip • Inferior Alveolar – Mandibular Teeth • Mental – Lower Lip

35. But 1st  Topical Anesthesia • Dry area w/ gauze • Hold swab w/ 4% lidocaine to area • ~ 2 minutes

36. Supraperiosteal Block • Individual tooth anesthesia • How to: • Pt closes mouth slightly, relaxed • Pull lip taut with gauze • Bevel facing bone, insert @ mucobuccal fold • Advance to apex • Aspirate • Inject 1-2 cc marcaine slowly

37. Infraorbital Nerve Block • Anesthetizes the midface • How to (intraoral approach): • Keep a finger over the inferior border on the infraorbital rim • Retract cheek • Puncture opposite the upper second bicuspid (premolar) ~0.5 cm from buccal surface • Needle parallel w/ tooth • Advance until palpated near the foramen (~2.5cm depth) • Aspirate • Inject 2-3cc marcaine adjacent to, not within, the foramen

38. Inferior Alveolar Nerve Block • Anesthetizes the hemimandible, lower lip & chin • How to: • Palpate the anterior ramus border • Retract buccal tissue laterally, stabilize mandible with finger behind ramus

39. Syringe barrel oriented over the contralateral mandibular bicuspids Insertion site = 1cm above occlusal surface of 3rd molar Insert until needle point touches medial surface of ramus Back up ~1mm Aspirate Inject Inferior Alveolar Nerve Block

40. Mental Nerve Block • Anesthetizes lower lip • Infiltration about the mental foramen • How to (intraoral approach): • Palpate the mental foramen ~1 cm inferior and anterior to the second premolar • Retract lip • Insert needle (45° angle) at mucosal junction of lower lip and gum beneath 2nd premolar • Aspirate • Inject 1-2cc marcaine

41. Billing For the Block • Specific code for dental anaesthesia (33.99B) no longer exists in Emergency • But….. • You can bill a local anaesthetic code 17.17A ($21.13), which is modifiable Thanks to Dr. Rick Morris

43. 5th Cranial Nerve: Trigeminal • V1 = Ophthalmic • V2 = Maxillary (dentition) • V3 = Mandibular (dentition)

44. Maxillary Nerve

45. Mandibular Nerve

46. Coe-Pak MSDS • Hazardous Ingredients • Denatured Alcohol 1-5% • Ethanol • Methanol • Petrolatum 5-10% • HEALTH HAZARD (Acute and Chronic): • Denatured alcohol: Prolonged exposure to ethanol may result in irritation of mucous membrane, headache, drowsiness, and fatigue. Methanol is also narcotic and affects are cumulative. • Sx & SYMPTOMS OF OVEREXPOSURE: Overexposure to methanol can result in acidosis and visual disturbances that may lead to permanent loss of vision.

47. Dycal MSDS